Aiming for a competitive specialty? Here is how to study for USMLE Step 1 in the Pass/Fail era
This post is part of How to med school for competitive specialties, click the hyperlink to see my other posts in the series
This might shape up to be a long post so buckle in. If you recently started medical school or will be starting soon, I recommend you first read my post about the general principles for studying efficiently during medical school. It will provide a framework for the rest of the post. This post will start with an overview of Step 1, the transition of Step 1 to Pass/Fail, the pitfalls of not granting Step 1 the respect it deserves, and finally, the study plan I used to study for Step 1 and thus prepare myself for the now-all-important Step 2.
USMLE Step 1 Overview
You need to pass all three of the USMLE’s Step exams to practice medicine unsupervised. However, physicians generally end up getting boarded in their particular specialty after completing their residency training so passing Step 3 is still a stepping stone to becoming competent in your future career. Medical schools can vary but Step 1 is taken after your preclinical work, generally at the end of your second year of medical school, Step 2 is taken after your third-year rotations, and Step 3 is taken during your first year or residency.
Step 1 Transition to Pass/Fail
Historically, all of the standardized exams were scored. Your Step 1 score was one of the most important components of your residency application and it was especially important to have a high score for competitive specialties. In January 2022, the USMLE transitioned score reporting to Pass/Fail. I have my own opinions about the change but what is done is done and we can only adjust to it. In 2023/2024, I was part of the first class to submit a residency application with a Pass/Fail Step 1. Given our situation was novel, medical school administrators scrambled to advise us on how to study for Step 1. The story that was handed down by my institution and many others was as follows.
Based on our data (students were required to take the CBSSA at the end of pre-clerkship courses before beginning their dedicated period), the majority of students are well above the passing mark for Step 1 before they start their dedicated period. Thus, for most of our students, the dedicated period is used to try to optimize their scores if they are interested in applying to competitive specialties. We recommend you study to the point that you are scoring ~10–15 points above passing and then schedule the real exam.
I didn’t subscribe to this advice and I will share why in the following paragraphs.
Why I didn’t sleep on Step 1
I have two main gripes with the logic of the advice I received regarding preparing for Step 1. First, the proposed strategy increased the likelihood of failing Step 1. Second, the strategy does not optimize for success on Step 2.
Failing Step 1
Failing step 1 effectively sinks your chance of matching into a competitive specialty. Below are images from the 2021 Residency Program Directors Survey showing how Otolaryngology programs consider Step scores for offering an interview and ranking applicants. I am biased towards ENT, but you can look up the data for whichever specialty you are interested in.
Not all programs consider whether there was a failed attempt with USMLE exams, but those that do rank that finding as very important. I think it is important to note that most programs likely don’t consider a failed USMLE attempt because most people that apply to competitive specialties don’t fail their USMLE exams. A failed USLME exam is important information for residency program directors to know because they want to make sure that their residents pass their boards and there is a fairly strong correlation between USMLE performance and the likelihood of passing your board exams [Dillon 2013].
In 2022, after the transition to Pass/Fail, the pass rate for Step 1 actually decreased. From 95% to 91% for MD students and 94% to 89% for DO students. One reason for the decrease is that the minimum passing score was increased from 194 to 196. Given the test is on a bell curve, shifting the curve guarantees that the failure rate will increase. However, I think another factor was more important to the decreased pass rate, and it was alluded to by the advisors at my institution. We were told, “the majority of students are well above the passing mark for Step 1 before they start their dedicated period”. However, this was only true for students who were expecting to take the exam for a score. I think it is reasonable to assume that taking the exam with a score provided students a proverbial kick in the rear to start studying earlier and/or study more rigorously during their second year before their dedicated period. Without a score, students are less likely to appropriately prepare. I believe this was compounded at my medical school given we had a pass/fail pre-clerkship curriculum. Doing well in our courses and being prepared for Step 1 was completely on the volition of the students. While, generally, medical students are very intrinsically motivated, I think this proves that the extrinsic motivation of doing well on Step 1 (or the fear of doing poorly) impelled students to prepare more effectively when there was a score associated with the exam. You really do need to prepare well for Step 1. Attaining even a passing score is no joke and if you wait until your dedicated study period to get down to preparing, it will be too little too late.
How Step 1 relates to Step 2
When I heard that Step 1 was transitioning to Pass/Fail, I was concerned with how I would build a stand-out application for a competitive specialty. Depending on the medical school you attend, your USMLE exams may be the only objective data you can send to residency programs to set yourself apart from other applicants. With this in mind, I had an inkling that residency programs would transition to weighting Step 2 more heavily than previously, effectively replacing applicants' Step 1 score with their Step 2 score. It turns out I was correct in my assumption [Wang 2021, Srinivasan 2024] but I didn’t know that definitively at the time. With Step 1 Pass/Fail, Step 2 is now the de facto objective measure for applying to residency programs. This means you need to prepare yourself to do as well as possible for Step 2. I also believe that you need to prepare yourself well for Step 1 to perform well on Step 2.
Step 1 and Step 2 are certainly different tests. Some might say that Step 2 is an easier test than Step 2 since it is less esoteric. Regardless, several studies both before and after the transition of Step 1 to Pass/Fail investigated the association between Step 1 and Step 2 performance among individuals, both showing a correlation of about 0.75 [Monteiro 2017, Kracaw 2021].
I acknowledge that both of these studies report correlations, and correlation does not equal causation. However, there are at least two reasons why the two tests are correlated with each other. First, at a bare minimum, scoring well on Step 1 may mean that you learned effective study skills that you can then apply to scoring well on Step 2. Second, there is a reason that they are called “Step” exams. There is an overlap between all three of them. They build off one another. As I mentioned, Step 1 tends to be more esoteric and specific compared to Step 2, but the questions asked in both exams are about the same underlying disease and patient scenarios. Thinking about it this way, if you can destroy Step 1 because you know every little fact about the pathophysiology of the most obscure diseases because you spent time drilling during your studies, then Step 2, which asks more generalized questions, should be a piece of cake. You will need to understand the elements that go into clinically applying the knowledge that you learned for Step 1, but you will already have a super solid foundation to anchor all of the new information on.
If you buy that there is content overlap between Step 1 and Step 2 then hopefully my next argument also makes sense. Your discretionary time for studying during your clerkships will drastically decrease compared to your pre-clerkship years. Since preparing for Step 1 is in many ways preparing for Step 2, you should maximize your time while you have it. Throughout medical school, I have tracked how I use my time. See the image below for my time differences between MS2 and MS3.
I had a huge shift from MS2, a time when I could be working at home at my desk on Anki, UWorld, Research, etc., to MS3, having responsibilities on the wards. The bottom line, you will feel like and objectively have much less time to study for Step 2 during your third year than for Step 1 during your second year. This effect is compounded by the time constraints placed by going on away rotations. If you are applying for a competitive specialty, you will be likely expected to rotate with at least one other institution during the beginning of your fourth year to experience a new setting, get a letter of recommendation, and/or show another program how good of a student you are.
If you think as I do, you are going to want to know your Step 2 score before you go on your away rotations to determine if you are going to be competitive for the specialty you are applying or should consider another specialty entirely. If you are going to have the score in hand before you begin your away rotations, then you are going to need to take the test between April and June and the end of your third/beginning of your fourth year. However, you will likely complete your core third-year rotations in March or early April. While that should still leave you with one month for a dedicated period, if your scores are not close to your target at the time you begin dedicated, you will not have enough time to adequately prepare for the exam and go on your away rotations with peace of mind.
My study plan for Step 1
Preclerkship performance
The first brick to place in preparing for Step 1 is by doing well in your pre-clerkship course, specifically the systems-based courses, and chipping away at practice questions throughout the entirety of your second year of medical school [Guilbault 2020]. I have previously written about my approach to studying during my second year and encourage you to read through it before proceeding through the rest of this article.
What Step 1 score should you aim for?
I recommend aiming for a practice Step 1 score that is within 5–10 points of the historical means score of matched applicants in your preferred specialty. See the image below from the 2022 Charting Outcomes Survey.
Should you take a dedicated study period?
With Step 1 Pass/Fail, it is my opinion that you can opt to not use a dedicated study period as long as you are efficient with your studying during your second year. While you don’t want to lay up on Step 1, there are still diminishing returns on studying for it as a proxy for preparing for Step 2 since if you are applying to a competitive specialty, you will also have a lot of pressure to publish research. There is an opportunity cost for studying for Step 1. Aim to not take a dedicated and then only take one if you absolutely need to since this will free up extra time to round out the other aspects of your residency application. In practice, on your second to last systems block, try to work ahead by watching Pathoma videos, learning Anki cards, and starting UWorld questions for both your current block and the last block. This is going to be a GRIND, but it will allow you to get the most accurate understanding of where your Step 1 score is before you decide whether to pursue a dedicated study period or not. One month before your potential dedicated period starts, start taking practice tests for Step 1. Many medical schools will have you take the CBSSA to guide you on when you should plan on taking Step 1. If this falls a month before your dedicated period would start, then take it then. Otherwise, take a different practice exam such as UWSA1. If your score on your first practice exam is within 10–15 points of your target score based on the historic averages for matched applicants in your preferred specialty, you don’t need to take a dedicated period after your courses are complete. Schedule your exam and get it over with. If you are further than 10–15 points from your target score, then take a dedicated period. I ended up scoring a 240 on the CBSSA one month before dedicated was supposed to start (before finishing UWorld) and decided taking a dedicated was not worth it. I took Step 1 less than one month after taking the CBSSA.
How to study after your initial practice test
After you have taken your first practice test and decided if you are going to take a dedicated study period or not, your first priority should be to finish all of your new UWorld questions. Once you have completed UWorld, retake all the questions that you got incorrect on your first pass. In my opinion, it is not necessary to make a full second pass through UWorld.
Leading up to your test date, aim to take one new practice test every week or two. There are several different practice tests to take such as UWSA1, UWSA2, the NBME’s, and the Free120. Use this Excel file (I reused the template from Step 1 for Step 2) to keep track of your progress on practice exams. After the CBSSA, I took UWSA1 (260), UWSA2 (258), and NBME 29 (252).
For all of the questions that you get incorrect or mark during the questions you do on practice exams, note them in an Excel spreadsheet. You can do this using this Excel file (I reused the template from Step 1 for Step 2). Mark any question in which you know you need to dig into the topic a little bit on Amboss to make sure you know it well. In general, you should take time to review the high-yield topics on the exam. These include acid/base, shock, fluids, and electrolytes. I found it helpful to go back and review the basic physiology of the major organ systems so that I could reason through questions rather than feel like I had to memorize every potential patient presentation. Unlock, reschedule to New, or make new Anki cards for all the questions you got incorrect or marked. On the last week before taking the real test, make a Word doc organizing the information you originally put in the Excel file with your incorrect and marked answers. Study off of this for the days leading up to the exam. The week of your exam, go through the bio stats and ethics questions in Amboss. Do not study anything except the Word doc the day before and the day of your exam.
There you have it. This was a long post, but I hope it helps frame your mindset for the importance of Step 1 for your future career aspirations while giving you actionable steps to make your goal score a reality. Once you crush Step 1, check out my post on how to study during your third year for Step 2.
